Giggle Incontinence…The “Not So Funny” Diagnosis

On a Monday morning, about six months ago, I readied my office for a new pediatric assessment. I was about to meet a 9 year old little girl whose mother had phoned our clinic after being told by her family physician that her daughter had enuresis risoria or “giggle incontinence”. Giggle incontinence has been defined as “the involuntary and often unpredictable loss of urine during giggling or laughter, in the absence of other stress incontinence” (Richardson and Palmer, 2016). Mom had spent endless hours on the internet researching her daughter’s diagnosis and came armed with several questions fueled by feelings of frustration, helplessness and an incredibly strong desire to help her child “be normal”.

I arrived up front and was met by a beautiful little blonde haired girl with big blue eyes and a smile that would have lit up any room! To anyone in our waiting room, she could not have appeared more “normal” but to Mom, she was “suffering silently”…and this is where our journey began.

Meet “M”!

My first hour with “M” was incredibly informative. Both Mom and “M” were talkative and provided detailed answers to my many questions. I asked a host of questions that I had outlined in order to determine first off, if this little girl was in fact struggling with giggle incontinence and secondly, what we were going to do to improve her quality of life! Mom explained that her daughter would unpredictably wet her pants during bouts of laughter. The incontinence would occur with hearty laughter or with a silly giggle! I continued with further questioning to determine if “M” presented with any other urge or stress incontinence issues. Did she leak when she coughed or sneezed? Did she leak when she played sports or jumped on the trampoline in the backyard? Did she leak when she had to go to the bathroom badly and struggled to pull her pants down quickly? Did she wet the bed at night? I explained to Mom that often there is more involved than simply urine leakage and the cause of this incontinence may be multi-leveled.

Based on the subjective portion of the assessment, I was able to conclude that my little patient was not experiencing any other outright incontinence. I went on to inquire about bowel function and movements and Mom reported that she did not feel constipation was an issue! However, when I presented my “poop chart” to my patient, she described her bowel movements as “corn on the cob or pellets” and reported that sometimes she had to “push really hard” and “sometimes it hurt a lot”. I put an asterisk beside this as an important point to return too. We also reviewed the patient’s bladder and bowel diaries and I was able to secure more information that may be playing a role in the incontinence. This allowed me to see what was going into her body and…what was coming out!

We moved onto the objective portion of the initial assessment and my patient was very excited when I explained that we were going to look at how her pelvic floor muscles were working and we were going to do this by playing a game on my computer. Of course the words “game” and “computer” always create an element of fun and my little patient reported “I never get to play games when I see my doctor”. I explained to “M” and mom that we were going to use something called biofeedback to determine how our muscles were working.

Biofeedback incorporates the use of surface electrodes which are placed around the anus and are connected to a feedback unit that tracks muscle activity while the physiotherapist cues different actions. I asked “M” to do different activities in a way in which she could understand. Phrases like “stop a toot” or “let you muscles go to sleep” allowed me to observe how her muscles are working in different situations. The print out then allows me to determine if the muscles are doing what might be expected during different activities. Does she relax her muscles fully or are they constantly “tight”? Is the muscle movement co-ordinated properly? Does she have the strength to contract the muscles and the endurance to hold the contraction? Richardson reported in The Journal of Urology that children must be able to “isolate, contract and relax perineal muscles” and that children can “heighten external urinary sphincter awareness and muscle recruitment using biofeedback techniques” (Richardson and Palmer, 2009). So not only does biofeedback provide useful assessment information, but also functions as a wonderful training tool to help children learn to use their pelvic floor muscles properly.

An incredibly informative assessment allowed me to devise a treatment plan that my patient, her mom, and I could work through in order to strive for “M’s” ultimate goal…”Keri, I want to be dry. I don’t want to have leaks”. Houser and Hahn (2009) reported that “laughter can cause a loss of muscle tone in the pelvic region. Another possible cause is that some people “hold” their urine too long, causing an overfull bladder. Constipation may be a further contributing cause”. “M” presented with all of the above characteristics and so our treatment journey began!

I asked Mom and “M” to complete a bowel and bladder diary which would detail void schedule, food and drink intake, leakage, and bowel movements. This allowed us to look at diet and detail some foods and drinks that may be causing irritation to “M’s” bladder. We also looked at fiber and hydration levels in order to combat constipation and relieve the pressure of the bowel contents on the bladder. Mom and “M” learned how the pelvic floor muscles work and how the bladder works and “M” began her “training” to become The Bladder Boss!

“M’s” treatments incorporated timed voiding schedules, learning to find her bladder, toileting positions, bladder emptying exercises, sensing urges and urge control, double voiding to ensure emptying and instruction in pelvic floor relaxation and contraction by way of exercise and biofeedback. With each visit, “M” would report her progress or her areas of struggle and we would celebrate and alter in an effort to achieve her goals!

Within 4 months of our very first visit, “M” was DRY and was having regular bowel movements! She was able to recognize urge and was able to control her pelvic floor muscles and she was no longer experiencing leakage…giggling or otherwise! She had successfully become The Bladder Boss and she could not have been happier! This was definitely something we could celebrate and giggle about!